What is the issue?
An outbreak of hepatitis A has been identified in Victoria. As of 12 January, 27 confirmed cases have been identified, and a further 12 cases of hepatitis A infection are being investigated. Of the 27 confirmed cases, all are male and most have not travelled overseas, indicating that hepatitis A is passing between men who have sex with men (MSM) in Victoria. A number of cases have visited sex on premises venues or report using dating apps or websites. Some cases are being identified in people who inject drugs.
The hepatitis A strains detected in this outbreak are similar to those circulating in Europe. Since 2016, hepatitis A outbreaks among MSM have been reported in 16 European countries and across the United States. A similar outbreak was reported in NSW in 2017, and people in other parts of Australia are also affected. In this outbreak, it appears that importations of hepatitis A are then leading to localised and persistent chains of transmission amongst risk groups, especially MSM and people who inject drugs, because of low levels of immunity amongst those populations.
Who is at risk of getting hepatitis A?
The two groups at greatest risk in this outbreak appear to be MSM and people who inject drugs, however local transmission to others has also been found.
High risk groups for hepatitis A infection include:
- Men who have sex with men (free vaccine is now available through 2018);
- People who inject drugs (free vaccine is now available through 2018);
- Other people whose lifestyle may increase risk of acquiring hepatitis A, including sex industry workers;
- People assessed by public health as close contacts of people with hepatitis A infection;
- People whose occupation put them at increased risk of acquiring hepatitis A, including staff working in early childhood education and care, carers of persons with developmental disabilities and plumbers or sewage workers;
- People with developmental disabilities, chronic liver disease, liver solid organ transplant recipients and those chronically infected with either hepatitis B or hepatitis C viruses;
- Travellers aged one year or more who are travelling to hepatitis A endemic areas.
Symptoms and transmission
Transmission is through the faecal-oral route and can occur when traces of virus are ingested, usually via contaminated hands, objects, water or food.
The incubation period for hepatitis A infection is between 15 to 50 days with an average of 28 days. People are infectious two weeks prior to symptom onset until around one week after the onset of jaundice or dark urine. This means people may transmit the infection to others for an extended period even before becoming unwell.
Adults who get hepatitis A usually develop symptoms, which include fever, nausea, vomiting and abdominal pain, followed by dark urine and yellow skin/eyes (also known as jaundice). Sometimes only some of these symptoms are present. Young children under five years of age infected with hepatitis A virus may have a mild illness with few or no symptoms, but can still transmit infection to others. Symptoms often last for several weeks, but full recovery usually occurs.
Prodromal symptoms may mimic influenza, so hepatitis A should be considered in the differential diagnosis for patients presenting with an influenza-like illness who have recent overseas travel to a high-risk country and/or MSM sexual activity or injecting drug use as risk factors.
Collect blood for serology (IgM) and liver function tests in any patient presenting with symptoms consistent with hepatitis A. If hepatitis A is confirmed, further testing will be undertaken by the Victorian Infectious Diseases Reference Laboratory.
Prevention and treatment
Advice for health professionals regarding this hepatitis A outbreak
- Offer a free, two-dose course of monovalent inactivated hepatitis A vaccine to all men who have sex with men who live in Victoria and all people who have injected drugs in the past 12 months and live in Victoria, available from 22 January 2018 until 31 December 2018.
- Testing is not necessary prior to vaccination. Individuals who have a documented history of hepatitis A immunity (because of previous vaccination or infection) do not require vaccination. While some groups are more likely to have had previous infection (e.g. those who spent their early childhood in an endemic area), testing is not generally indicated as it may delay protection, and there are no safety concerns in vaccinating patients who have prior immunity.
- Consider hepatitis A infection in patients presenting with a compatible clinical illness, especially those who are MSM or a person who injects drugs. Take blood for serology (IgM) and liver function tests, advise against sexual activity and food preparation for others, and notify the Department immediately by calling 1300 651 160. This notification will enable other public health control measures to be taken.
- While waiting for results of hepatitis A testing, advise your patient to avoid sexual activity, and to avoid work as a food handler, as a child care worker and as a health care worker. They should also not prepare food for others during this time.
- If hepatitis A is confirmed, your patient should avoid any sexual activity, and should not prepare food or drink or share utensils, nor provide personal care for others, share linen or towels, or donate blood.
- Advise MSM against engaging in high risk sexual practices, including attending sex on premises venues, as such practices may increase the potential for transmission.
Advice for health professionals regarding meningococcal ACWY vaccine and HPV vaccine for MSM in 2018
- The Department announced a free meningococcal ACWY vaccine campaign in December 2017 for MSM. This offer has now been extended until 31 December 2018.
- The Department is expanding access to free HPV vaccine (Gardasil®) for MSM aged up to 26 years who have not previously received a course. The vaccine will now be available through all immunisation providers in Victoria until 31 December 2018. This is a three-dose course, normally given at zero, two and six months.
- Arrangements for hepatitis B vaccine as a free vaccine to Victorian MSM continue.
- The initial dose of vaccines against these four conditions can be given as four injections during a single consultation, with subsequent doses required for hepatitis A, hepatitis B and HPV at later intervals.
- If you are an immunisation provider you can now order free hepatitis A, hepatitis B, meningococcal ACWY and HPV vaccine for your MSM patients or clients using the Department's online ordering form.
Advice for patients
- From 22 January 2018 until 31 December 2018 all MSM who live in Victoria, and all men and women who have injected drugs in the past 12 months and live in Victoria, will be able to get access to a free, two dose course of hepatitis A vaccine.
- Throughout 2018, the Department is recommending a single dose of meningococcal ACWY vaccine for MSM regardless of age, and is also offering a course of HPV vaccine to MSM aged up to 26 years in order to protect against HPV-related cancers.
Online vaccine order forms
Important health information for men who have sex with men: a guide for health professionals and immunisation providers
Important health information for people who inject drugs: a guide for health professionals and immunisation providers
Better Health Channel: Time to Immunise